Improving public hospital and outpatient clinic performance

Introduction

Hospital performance can be defined as achievement of desired clinical or administrative targets (1). Public hospitals are fast approaching a crisis due to sub optimal performance. We have finite resources to meet infinite heath demands of our ageing population. Even in an advanced economy like Australia there will never be enough resources for meeting health care demands, investing in latest technology and research. Improving performance is critical to best serve our society.

Sub-optimal public hospital performance in several hospitals across Australia is causing strain on our healthcare. Australian Institute of Health and Welfare hospital report card demonstrates decline in performance indicators in public hospitals across Australia. More than 30% of ‘Category 3 patients’ presenting to the emergency department are not assessed within clinically recommended 30 minutes (2). There is a 17% decline from previous year in meeting ‘Category 2’ elective surgery timeframe across Australia (2). This is despite increasing cost from previous years. Ineffective utilisation of organisational resources (3) is one of the reasons that hospitals are unable to achieve performance targets.

Ineffective utilisation of resources has a significant impact to the society as hospitals are key to health care system. Health care inefficiencies have been attributed to approachably 100,000 deaths and 1 million injuries annually in the United States (4). Poor performance impacts hospital credibility as information on hospital performance is increasingly available publicly. This in turn impacts staff morale. Hospitals take up a significant proportion of national expenditure and poor hospital performance leads to loss of opportunities elsewhere in the economy.

Discussion

Major factors and impact on key stakeholders

Most important and expensive resource in any hospital is the staff. At the macro-level national healthcare polices do not sufficiently support improved individual staff performance and this negatively impacts hospital performance overall. For example, there is no incentive for doctors from inpatients teams to clear patients from emergency department in a timely manner. There is no incentive for theatre nursing, anaesthetic or surgical staff to improve theatre efficiency. ‘Independent Hospital Pricing Authority’ (IHPA) funds hospitals using an activity-based funding (ABF) model (5). ABF is a fee-for-service payment model where hospitals are allocated a fixed price for each care episode. While the ABF based payment model makes some adjustments like reducing funding if complications are present during admission, it does not directly attach funding to improved patient outcome during their hospital stay. This does not provide individual clinicians or departments with tangible benefits to improve efficiency in a public hospital.

At the meso-level several factors impact performance. Recent systematic review identified five domains that are common in poorly performing healthcare organisations. These are poor organisational culture, inadequate infrastructure, lack of a cohesive mission, system shocks due to major changes and dysfunctional external relations (6). A hierarchical organisational structure with non-collaborative leadership approach can lead to employees losing sense of ownership, frustration and lack of trust. This negatively impact organisational performance as it leads to poor organisational culture.

At the micro-level poor staff well-being is an important factor that can impact staff performance. There is an increase in hospital staff burnout, compassion fatigue and low sense of personal accomplishment (7). Coronavirus disease 2019 (COVID-19) pandemic had led to worsened stressors in hospital staff that was already over-worked to meet increasing demands of our stretched workforce. Majority of us have firsthand experience where burnout has led to reduced motivation, creativity to solve problems, lower energy at work and this has negatively impacted work efficiency.

Leadership strategies

Happy and healthy healthcare team is the cornerstone to successfully caring for patients. We need to reward individual performance. A macro-enabler can be introduction of outcome-based funding programs like P4P schemes. These schemes are commonly used in United States by providing medical practitioners financial rewards for meeting specified benchmarks (8). I work in a public and a private hospital. There is a notable difference in efficiency of anaesthetic and surgical staff in private hospitals as staff have monetary incentive to work quicker. Health leaders can improve performance by offering additional monetary and non-monetary incentives.

Value based healthcare is an alternative model in which providers (practitioners and hospitals) are funded based on patient health outcomes. Its benefit is increasingly been utilised by medical administrators in the United States. A systematic review of fifty-nine studies on cost, quality, spending and resource utilisation on value-based payment models in insurance sector demonstrated improved quality outcomes (81% of studies), reduced spending (56% of studies) and improved utilisation in 58% of studies (9). It is proven to improving patient experience, population health, and reducing the per capita cost (10). It is likely that in Australia we will be utilising bundled payments for care cycle in near future. Some leadership strategies to help us best prepare for this change and improve performance include defining patient needs across care cycle, grouping them into practice units (example multi-disciplinary foot unit) and investing in technological and non-technological solutions that assist in measuring outcomes.

Appropriate leadership strategies are key meso performance enabler. The complex problem of managing hospital performance requires leadership approaches that improve organisational culture, enhance staff commitment and promotes innovative ideas for supporting growth and change. This cannot be achieved by traditional transactional or autocratic leadership approach. A hierarchical organisational culture, characterised by transactional or autocratic leadership styles suppresses input from staff members, fostering feelings of frustration and stress among team members. These emotional repercussions can result in suboptimal team dynamics, hindered communication, and adverse effects on patient care (11). There is substantial evidence, particularly in nursing research, indicating that positive leadership practices among nurse managers are linked to a decrease in adverse events and an improvement in the quality of patient care (12).

Hospital-level healthcare leaders need to be educated in implementing above principles. Ensuring our health leaders are trained in non-traditional leadership approaches needs to be addressed as part of recruitment. Leadership behaviours like active listening, building trust and ensuring that teams are well-structured with few layers of hierarchy is essential to improving hospital performance. Checking healthcare leaders have undertaken relevant leadership courses and develop appropriate skills can be included as part of credentialing process. This will ensure that health leaders have skills to engage with staff better and use non-financial measures to help incentive performance.

Hospital staff well-being is a key micro-enabler to improve performance. Hospitals need to invest resources in ensuring staff well-being. Some practical initiatives that can be implemented are ensuring appropriate roasters, offering mindfulness-based stress reduction programs and access to on-site facilities for healthy food, places for relax and participate in exercise. A culture of wellness will ensure that staff are healthy. This will ensure that they make less mistakes, are efficient and connected to organisational goals.

National and state regulatory bodies also play a crucial role in ensuring that these standards are upheld, providing guidelines and oversight to safeguard the welfare of healthcare workers across the country. By monitoring compliance with regulations and swiftly addressing any deviations, these regulatory entities contribute significantly to fostering a safe and supportive environment for healthcare professionals to deliver quality care to patients. These strategies foster a more resilient and effective clinical team in outpatient settings such as general practice and sports medicine clinics. Effective clinic managers who monitor staff well-being can enhance efficiency and responsiveness to patient needs, ensuring a high standard of care in their clinics.

Recommendations

There are no ‘silver bullets’ to improve the complex problem we face in improving performance of public hospitals. We need to implement multiple approaches and titrate them to improve outcomes. Some recommendation to improve hospital performance include:

• Rewarding individual performance by providing variety of monetary and non-monetary incentives. These can include P4P schemes in areas like elective surgeries in short term and bundle payments in long term for value-based incentives like management of chronic issues like diabetes, heart failure and back pain. Personalised thankyou notes, recognition in hospital new letters and vacation benefits to employees that meet performance thresholds can also be used to reward staff.
• Ensuring our health leaders are trained in non-traditional leadership approaches as part of recruitment and credentialing process.
• Investing in monitoring and improving staff wellbeing.

Acknowledgments

Funding: None.

Footnote

Peer Review File: Available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-9/prf

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://jhmhp.amegroups.com/article/view/10.21037/jhmhp-24-9/coif). The author has no conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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